Provider Demographics
NPI:1790950798
Name:WAGNER, DANIEL BEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:BEN
Last Name:WAGNER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14808 PHYSICIANS LN
Mailing Address - Street 2:111
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3942
Mailing Address - Country:US
Mailing Address - Phone:301-869-1017
Mailing Address - Fax:240-235-4353
Practice Address - Street 1:14808 PHYSICIANS LN
Practice Address - Street 2:111
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3942
Practice Address - Country:US
Practice Address - Phone:301-869-1017
Practice Address - Fax:240-235-4353
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017505103T00000X
MD04954103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist